Clinical Services

The initial patient encounter with a cancer system often happens in an office or clinic, where cancer-related ambulatory procedures, such as clinical visits, physical examinations, Pap smears, blood samples, or endoscopies, can take place. Guidelines help to determine when and where these procedures should occur and how they should be provided properly and safely by trained staff. Ambulatory facilities may need special equipment to address the needs of various patient populations, for example, special examining tables for gynecologic malignancies, and chairs and special endoscopic equipment for assessing head and neck cancers. Depending on the activity and jurisdiction, special facilities to support these procedures may be required and should be accredited.

Imaging is a critical technology for diagnosis, to assess the effects of cancer treatment and complications, monitor for the recurrence of cancer, and screen the general population for cancerous conditions. It also is used to guide interventional procedures such as biopsies under ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI); securing of vascular access; and therapeutic interventions, such as embolization and high frequency ultrasound tumor ablation. Imaging for cancer ranges from conventional X-rays to ultrasound, CT, MRI, and molecular imaging (nuclear medicine) with position emission tomography, frequently combined with CT.

Imaging services require equipment and specialized staff, such as radiologists and radiology technologists, to operate and maintain the equipment. International organizations, such as the International Atomic Energy
Agency, the International Society of Radiology, and WHO, have developed and published standards and guidelines for the safe installation, operation, and use of imaging equipment. This information is used to create national and regional standards (for example, Radiation Safety Institute of Canada 2014; Zaidi 2010). Picture archiving and communication systems and webbased systems allow for offsite evaluation and reporting of images and are useful in management of care in remote communities, remote mentoring, and quality control initiatives. These processes are especially useful in limited-resource settings.

Pathology and laboratory medicine, including blood banking, are essential for diagnosing cancer by examining patient biologic specimens. Laboratory medicine services include pathology, hematology, biochemistry, microbiology, and, increasingly, cytogenetic and molecular testing, services that are not specific to cancer.

Pathology and laboratory medicine services require facilities equipped to handle biological specimens with appropriate precautions, and specialized equipment to process and analyze tissues, blood, serum, and body
fluids. Basic pathology can include the capability for specimen fixation, embedding into paraffin, tissue slicing,
and staining; modern facilities must include immunohistochemistry, flow cytometry, and molecular and cytogenetic testing (Gralow and others 2012). Given that the diagnosis of cancer, especially rare cancers, is complex, subspecialty expertise or access to such expertise via international networks is required. Collaborative or twinning initiatives have been developed to support pathology services in LMICs. Examples include a Ghana-Norway partnership as part of the Breast Health Global Initiative (Masood and others 2008) and Partners in Health, which includes clinics in a number of LMICs (Haiti and Rwanda) with close ties to the Brigham and Women’s Hospital and Dana-Farber Cancer Institute (Carlson and others 2010). Laboratories require specialized accreditation to ensure that processes are in place to optimize the quality of specimen procurement and reporting.

Surgery is a fundamental element of cancer treatment. Well-established interventions have proven effective in reducing surgical risk and provide promising strategies to improve outcomes (Weiser and Gawande 2015). The introduction of standardized practices, such as the Surgical Safety Checklist endorsed by WHO, has improved the outcomes of surgical procedures in countries at all economic levels (Farmer and others 2010; Gawande 2009; Haynes and others 2009; Lingard and others 2008; Lingard and others 2011; World Alliance for Patient Safety 2008). The
use of comprehensive standard policies and procedures facilitates safe and efficient operations.

Radiation therapy, or radiotherapy, involves the use of ionizing radiation for therapeutic purposes. Strategies to 200 Cancer improve access to radiotherapy in LMICs have been suggested, including offering basic treatment techniques and optimizing fractionation to increase the throughput on radiotherapy machines, encouraging competitive pricing, and supporting long-distance mentorship for programs in remote areas (Gralow and others 2012). For many reasons, cobalt machines have frequently been considered more appropriate for LMICs (IAEA 2008, 2010). These views are changing as access to more sophisticated technologies is improving. Although linear accelerators require a more reliable power supply, cobalt units present a higher radiation safety risk and require frequent source replacement, which presents a hazard and additional expense.

In systemic cancer therapy or chemotherapy, drugs are distributed in the body through the bloodstream.
These drugs include chemotherapy, administered intravenously or orally; hormones; and immune and molecular- targeted therapies. Systemic therapy is used alone or in combination with surgery and radiotherapy
to reduce recurrence, improve survival (Gralow and others 2012; Valentini, Barba, and Gambacorta 2010), and help preserve organs. Chemotherapy alone is used in hematologic cancers and in most metastatic cancers. Chemotherapy facilities can be used for other intravenous treatments, transfusions, minor procedures such as bone marrow biopsies, thoracentesis, paracentesis, and lumbar puncture for cancer and noncancerous conditions. Systemic therapy can usually be delivered in specialized ambulatory facilities in hospital outpatient units and community-based medical offices or clinics.

Chemotherapy drugs may be expensive, although a host of agents are now off patent and can be effective and
used extensively in LMICs (Konduri and others 2012). Several of the cancers endemic to the lowest income settings are amenable to treatment with relatively low-cost chemotherapy, but treatment cost is still a major barrier for many in LMICs.

Palliative care aims to prevent or relieve suffering, provide early identification and assessment of symptoms, and address other physical, psychosocial, and spiritual issues (WHO 2006a). It is the subject of chapter 9 of this volume (Cleary, Gelband, and Wagner 2015).

Survivorship is defined as the care of persons diagnosed with cancer, from the time of diagnosis throughout their lives, as well as the impact of cancer on family members, friends, and caregivers of survivors (Centers for Disease Control and Prevention 2013).

Increasingly, as treatments become more successful and life expectancy increases, patients face new issues. With improvements in access to and quality of care, this will increasingly be the case in LMICs, where survivorship services are currently unavailable.

Psychosocial support can be provided to patients and their families by a broad range of people, depending on the level of need. Complex mental health issues and social matters can benefit from the engagement of other health professionals, including primary care providers, community health workers, spiritual guides, volunteers, friends, families, and other lay individuals. Comprehensive cancer centers should have a survivorship program with a range of professionals, including psychiatrists, psychologists, social workers, nurses, therapists, nutritionists, and educators, as well as patients in treatment and long-term survivors.